Case Study in Nursing Plan - Assessment, Diagnosis, Goal, Implementation, Evaluation

Running head: CASE STUDY IN NURSING PLAN
CASE STUDY IN NURSING PLAN
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CASE STUDY IN NURSING PLAN1
Case Study of Client: Assessment
A case study of 65-year-old patient was taken for the study and understand the care
plan. At first his blood sugar and blood pressure were checked. The results showed that the
old man was suffering from diabetes and had high blood pressure. He had experienced minor
stroke in the past, which states that he is at high risk of heart related ailments. He complained
of acute shortness in breathing and one year ago he was admitted to the hospital for acute
chronic obstructive pulmonary disorder. The person uses ventilator support every night since
one year since diagnosed with COPD. The person was further asked if he had any major
fever, diarrhoea or abdominal pain to which he replied that he had never experienced severe
problem except for some mild fever, which is common. Upon evaluating the medical history
of his family, it was concluded that he was at high risk of cardiovascular disease but not any
genital disorder. The blood glucose results were not shocking as he showed symptoms of
diabetes like more frequency in urine and tiredness (Adam, Osborn & Welch , 2017). The
patient confirmed that he leads a healthy life by consuming a balanced diet with less
consumption of sugar and fatty substances and goes for walking every morning. He used to
consume tobacco but has left 10 years back. No serious surgeries were performed on him,
however he complained of pain in legs and joints, which make it difficult for him to stand or
walk. This problem is common in this age and may be as a result of osteoporosis therefore he
must consume calcium in food or in the form of supplements. The man is currently under no
medication except for a ventilator system for shortness in breathing. He sometimes take some
medications for mild fever which was prescribed by his physician. The patient’s family
history showed high risk of cardiovascular disease. The patient had high blood pressure and
blood glucose levels as per physical examination. The patient takes ventilator support for
uneasiness in breathing. .He complained of pain in his legs which is common in this age.

CASE STUDY IN NURSING PLAN2
The person does not consume tobacco and leads a balanced life therefore at low risk of
obesity and related illness.
Assessment Diagnosis Goal Implementatio
n
Evaluation
 The patients
family
history
showed high
risk of
cardiovascula
r disease.
 The patient
had high
blood
pressure and
blood glucose
levels as per
physical
examination
 The patient
takes
ventilator
support for
uneasiness in
breathing.
 He
complained
of pain in his
legs which is
common in
this age.
 The person
does not
consume
tobacco and
leads a
Based on
assessment it
is revealed
that the
patient needs
to take care
of his
cardiovascula
r health due
to inadequate
cardiac
output
(Kinchen,
2015
1. The patient
is suffering
from
hyperglycaemi
a and control
of blood sugar
is important
(Allen et al.,
2014)
1a) To verify
the patient
understands the
importance of
taking insulin in
time. Rationale:
identify the
need of change
in insulin.
1b) To make the
person follow
diet containing
low sugar.
Rationale: low
fat diet controls
cholesterol.
(Wong, 2014).
1c) To teach
patient about
adjusting insulin
injection.
Rationale:
multiple
injection causes
fat deposits
(Broderick &
Coffey, 2013).
1A)
Detection of
diabetes
abnormalities
.
1b) Review
of risk factors
controlled in
the patient.
1c) To
provide basis
for
continuation
of care.